Referrals | Substance Abuse Resource Assistance Coalition

County of Referral*

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Referral Date*

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Client Information

First Name*

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Last Name*

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Street Address*

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City*

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State/Province/Region*

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Zip/Postal Code*

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Home Phone*

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Cell Phone*

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Ages of children in the house (select all that apply)

0-6

7-12

13-17

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Reason for Referral*

Transportation

Food Insecurity

Behavioral Health Resources

Utility Assistance

Clothing Needs

Substance Use Resources

Other

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Referrer Information

Referring Partner*

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Name of Person Referring*

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Email*

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Phone*

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Partnership Report

DIRECTIONS:
Please complete the report for clients referred to the SARAC Resource Center.

VICTIM SERVICES:
This set of questions asks about the provision of direct services to crime victims. Report all victims served through your OVC-funded program in this section.

DEMOGRAPHICS:
Enter the count of individuals referred.

Race/Ethnicity (Select all reported)*

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White Non-Latino or Caucasian

Some other race

Multiple races

Not reported

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Gender Identity (Select all reported)*

MaleFemaleOtherNot reported

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Client Victimization Type (Select all reported)*

Adult Physical Assault (Includes aggravated and simple assault)

Adult Sexual Assault

Adults Sexually Abused/Assaulted as Children

Arson

Bullying (Verbal, Cyber or Physical)

Burglary

Child Physical Abuse or Neglect

Child Pornography

Child Sexual Abuse/Assault

Cyber Crimes

Domestic and/or Family Violence

DUI/DWI Incidents

Elder Abuse or Neglect

Gang Violence

Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other

Human Trafficking: Labor

Human Trafficking: Sex

Identity Theft/Fraud/Financial Crime

Kidnapping (Noncustodial)

Kidnapping (Custodial)

Mass Violence: Domestic/International

Opioid/Alcohol/Substance Abuse in Household

Other Vehicular Victimization

Robbery

Stalking/Harassment

Survivors of Homicide Victims

Teen Dating Victimization

Terrorism (Domestic/International)

Other

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Other (Please Explain)*

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Evidence Based Practices

This section of questions asks about Evidence-Based Practices (EBPS) used by the referring partner. Evidence-based programs or practices are best practice models that include program models that have been shown through rigorous evaluation and replication to be effective.

Did you use EBPS when serving this client?*

YesNo

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Client Information

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